MANAGEMENT

TUBERCULOSIS
OF SPINE
By Dr Shahid Latheef
Department of Orthopaedics
Yenepoya Medical College
Mangalore

Introduction
The primary problems today are :

The delay in diagnosis (average 3months)

The long recovery period (average 12months)
The great cost of treating such infections.
Resurgence in HIV patients.
Paralysis is reported to occur in up to 50% of
patients with spinal infections .

BASIC PRINCIPLES OF
MANAGEMENT
Early diagnosis
Expeditious medical treatment
Aggressive surgical approach
Prevent deformity
Best outcome
The captain of the men of death

SPINAL TUBERCULOSIS
C/F
Presentation depends on :
Stage of disease
Site
Presence of complications such as neurologic
deficits,
. abscesses, or sinus tracts.
Average duration of symptoms at the time of
diagnosis is 3 4 months.
Back pain is the earliest & most common symptom.
Constitutional symptoms.
Neurologic symptoms (50 % of cases).

SPINAL TUBERCULOSIS
C/F
Physical examination of the spine :
Localised tenderness and paravertebral muscle
spasm,
Kyphotic deformity
Cold abscess / swelling / sinus tract
Cervical spine TB is a less common
presentation, characterized by pain & stiffness with
dysphagia / stridor more common in lower cervical
spine involvement

SPINAL TUBERCULOSIS
INVESTIGATION
LAB STUDIES
Mantoux / Tuberculin skin test
ESR may be markedly elevated (neither
specific nor reliable).
ELISA : for antibody to mycobacterial antigen6 , sensitivity of 60 80%.
PCR

INVESTIGATION

Microbiology studies to confirm diagnosis

Ziehl-Neelsen staining: Quick and inexpensive
method.
Bone tissue or abscess samples stain for
acid-fast bacilli (AFB), & isolate organisms for culture
& drug susceptibility.
Culture results - few weeks.
Positive only in 50% of cases.

INVESTIGATION
RADIOLOGICAL DIAGNOSIS
1. PLAIN RADIOGRAPH
2. CT SCAN
3. MRI SPINE
4.BONE SCAN

PLAIN RADIOGRAPH
More than 50% of bone has to be destroyed.
May take approximately six months.
The classic roentgen triad in spinal tuberculosis is
primary vertebral lesion
disc space narrowing and
paravertebral abscess.

PLAIN RADIOGRAPH
Typical tubercular spondylitic features in long standing
paraspinal abscesses
a} produce concave erosions around the anterior
margins of the vertebral bodies producing a scalloped
appearance called the Aneurysmal phenomenon.
b} fusiform paraspinal soft tissue shadow with
calcification in few
Skip lesions as involvement of non contiguous
vertebrae (7 10 % cases).

PLAIN RADIOGRAPH
DEFORMITIES:
. Anterior wedging
. Gibbous deformity.
. Vertebra plana = single collapsed
vertebra

CT
Patterns of bony destruction.
Calcifications in abscess (pathognomic for Tb)
Regions which are difficult to visualize on plain films,
like :
1. Cranio-vertebral junction (CVJ)
2. Cervico-dorsal region,
3. Sacrum
4. Sacro-iliac joints.
5. Posterior spinal tuberculosis because
lesions less than 1.5cm are usually missed due to
overlapping of shadows on x rays.

MRI
Lack of ionizing radiation, highcontrast resolution &
3D imaging.
Detect marrow infiltration in vertebral bodies, leading
to early
diagnosis.
Changes of diskitis
Assessment of extradural abscesses / subligamentous
spread.
Skip lesions
Spinal cord involvement.
Spinal arachanoiditis.

USG
- to find out primary in abdomen
- Detect cold abscess
- Guided aspiration

Radionucleotide Scan

T 99m
Increased uptake in up to 60 per cent patients with active
tuberculosis.
>= 5mm lesion size can be detected.
Avascular segments and abscesses show a cold spot due to
decreased uptake.
Highly sensitive but nonspecific.
Aid to localise the site of active disease and to detect
multilevel involvement

EXTRA-DURAL INVOLVEMENT
Patterns of Vertebral Involvement
The primary focus of infection in the spine can
be either in the vertebral body or in the posterior
elements.

Four patterns :
Paradiscal ( Commonest)
Central
Anterior, &
Appendiceal

SPINAL TUBERCULOSIS
TYPES..
1. Paradiscal Lesions:
Most common
Adjacent to the I/V disc leading to a narrowing of the disc
space.
Destruction of subchondral bone with subsequent
herniation of the disc into the vertebral body or by direct
involvement of the disc.
MR imaging shows low signal on T1-weighted images and
high signal on T2-weighted images in the endplate,
narrowing of the disc, and large paraspinal and sometimes
epidural abscesses.

TYPES.

2. ANTERIOR TYPE

Subperiosteal lesion under the ALL.

Pus spreads over multiple vertebral segments
Strips the periosteum and ALL from the anterior
surface of the vertebral bodies.
Periosteal stripping renders the vertebrae avascular
and susceptible to infection.
Both pressure and ischemia combine to produce
anterior scalloping

Anterior type.
Collapse of the VB & diminution of the disc space is
usually minimal & occurs late.
More common in thoracic spine in children.
MR imaging shows the subligamentous abscess,
preservation of the discs, and abnormal signal
involving multiple vertebral segments representing
vertebral tuberculous osteomyelitis.

TYPES.

3. Central Lesions :
Centred on the vertebral body.
Batsons venous plexus or posterior
vertebral artery.
Disc not involved.
Vertebral collapse occur - vertebra plana
appearance.
MR - signal abnormality of the vertebral
body with preservation of the disc.
DD: Appearance is indistinguishable from
that of lymphoma or metastasis.

Types...
4) Appendicial lesion
Isolated Pedicles & laminae (neural arch),
transverse processes & spinous process.
Uncommon lesion (< 5%).
? In conjunction with the typical paradiscal
Variant
Radiographically - erosive lesions,
paravertebral shadows with intact disc space.
Rarely, present as synovitis of facet joints.

Paravertebral abscess

Collapse of the vertebral body

Tuberculous granulation tissue + caseous matter +
necrotic bone
Accumulate beneath the anterior longitudinal ligament.
Gravitate along the fascial planes
Present externally at some distance from the
site of the original lesion.

Tubercular abscess
Cervical region
- b/w vertebral bodies , pharynx and trachea
Upper thoracic
- V shaped shadow , stripping lung apices
laterally and downwards
Below T4 fusiform shape (bird nest appearence)
Below diaphragm unilateral / bilateral psoas
shadow

DEFORMITIES IN SPINAL
TUBERCULOSIS
POTTS SPINE
Kyphosis
1-2 knucle
3 or more Angular (Gibbus)
More Round kyphosis
Scoliosis

Clinico radiological classification

(Kumar 1988)

DIFFERENTIAL DIAGNOSIS

SPINAL INFECTIONS- pyogenic, brucella & fungal.

NEUROPATHIC spine
NEOPLASTIC commonly lymphoma/ metastasis
DEGENERATIVE
Biopsy is definitive.

Tubercular
Pyogenic
Long standing history of

History of days to months.

months to
Years
Not present.
Presence of active
pulmonary
tuberculosis -60%
Most common location
thoracic spine
followed by thoraco-lumbar
region.
> 3 contiguous vertebral
body
involvement common- 42%.

Most common location

lumbar spine.

19% only. Mostly involves

1 spinal
segment 2vertebrae &
intervening
disc.
21% only.

Tubercular
Pyogenic
Bone destruction : 73%

48%

Posterior elements
involvement
common

Rare
Rare

Skip lesions common

Disc is involved with less
frequency
and severity. Disc spared in
central
type TB.
Paraspinal and epidural
abscesses60%

Disc destruction is most often

seen in
pyogenic osteomyelitis.

Tubercular
Pyogenic
Paraspinal and epidural
abscesses60%
1. large involving many
contiguous
vertebral bodies level
2. calcification if present is
pathognomic.
3. Smooth rim
enhancement -74%
TO SUMMARISE: atypical

30%
1. Rare
features + abscess
character.
2. Not seen.
3. Heterogenous
enhancement. Thick
irregular Rim
enhancement only 9%
cases.

DD : BRUCELLA SPONDYLITIS
Predilection for the lumbar spine.
Intact vertebral architecture
despite evidence of diffuse
vertebral osteomyelitis.
Gibbus deformity rare.
Smaller paraspinal abscesses
Facet joint involvement

DD: NEUROPATHIC SPINE

Patients with diabetes mellitus,
syringomyelia, syphilis, or
other neuropathic disorder
Destructive changes in the
vertebralbodies large osteophytes,
extensive vertebral sclerosis.
Loss of disk space but no hyperintensity
or enhancment
No paraspinal soft-tissue lesion

DD: NEOPLASTIC
Tubercular
A destructive bone lesion
associated with a poorly
defined
vertebral body endplate,
with or
without a loss of disk
height,
suggests an infection,
which has a
better prognosis

Neoplastic
A destructive bone
lesion associated with a
well preserved
disk space with sharp
endplates suggests
neoplastic
infiltration.

Good disk, bad news;

bad disk, good news"

Central type TB

Differential diagnosis
Children
Congenital anomalies of spine

Hemivertebra
Block vertebra
Defect or synostosis of neural arc
No signs and symptoms of TB, no
paravertebral shadow
/ associated anomalies
Calves disease

Adolescents
Scheurmans disease
-ischemic lesion of appophysis of several vertebra
-rounded kyphosis
-minimal local symptoms
Schmorls disease

Complication of spinal
tuberculosis

Paraplegia
Cold abscess
Spinal deformity
Sinuses
Secondary infection
Amyloid disease
Fatality

TUBERCULOUS SPINE WITH

PARAPLEGIA

Incidence : 10 30 %
Dorsal spine most common
Motor functions affected before / greater than
sensory.
Sense of position & vibration last to disappear.

PATHOLOGY OF TUBERCULOUS
PARAPLEGIA
Inflammatory Edema :
Vascular stasis , Toxins.
Extradural Mass :
Tuberculous osteitis of VB & Abscess.
Meningeal Changes : Dura as a rule not involved
Extradural granulation --- Contraction / Cicatrization
---Peridural fibrosis ---- Recurrent Paraplegia

PATHOLOGY OF TUBERCULOUS
PARAPLEGIA..
Bony disorders :
Sequestra , Internal Gibbus
Infarction of Spinal Cord :
Endarteritis, Periarteritis or thrombosis of tributary
to ASA.
Changes in Spinal Cord :
Thinning (Atrophy), Myelomalacia & Syrinx

SEDDONS CLASSIFICATION OF
TUBERCULOUS PARAPLEGIA
GROUP A (EARLY ONSET
PARAPLEGIA) a/k/a Paraplegia
associated with active
disease :

GROUP B (LATE ONSET

PARAPLEGIA) a/k/a
Paraplegia associated with
healed disease :

Active phase of the

disease within first 2 years of
onset.

After 2 years of onset

of disease.

Pathology inflammatory edema,

granulation tissue, abscess,
caseous material or ischemia
of cord.

Recrudescence of
the disease or due to
mechanical pressure on the
cord.

Pathology can be
sequestra, debris, internal
gibbus or stenosis of the
canal

KUMARS CLASSIFICATION OF TUBERCULOUS

PARA/TETRAPLEGIA (Predominantly based on motor
weakness)

MANAGEMENT

MIDDLE PATH REGIME

Rest in hard bed

Chemotherapy
X-ray & ESR once in 3 months
MRI/ CT at 6 months interval for 2 years
Gradual mobilization is encouraged in
absence of neural deficits with spinal braces
& back extension exercises at 3 9 weeks.
Abscesses aspirate when near surface &
instil 1gm
Streptomycin +/- INH in solution

MIDDLE PATH REGIME.

Sinus heals 6-12 weeks
Neural complications if showing progressive
recovery on ATT b/w 3-4 weeks -- surgery
unnecessary
Excisional surgery for posterior spinal disease
associated with abscess / sinus formation +/neural involvement.
Operative debridementif no arrest after 3-6
months of ATT / with recurrence of disease .
Post op spinal brace18 months-2 years

DRUGS IN MIDDLE PATH

REGIME

Various Regimes for Spinal TB

3 (HRZE) / 3 (HRZS) + 3 (HRZ) + 12 (HR)
Pediatric age group, Streptomycin (for
two months) replaces Ethambutol to avoid optic
neuropathy .
4 (HRZE) + 14(HR)

EVOLUTION OF SURGICAL
TREATMENT
Artificial abscess- Pott (1779)
Laminectomy & laminotomy : Chipault (1896 )
Costo-transversectomy: Menard (1896)
Calves operation (1917)
Lateral rhachiotomy of Capener (1933)
Anterolateral decompression of Dott &
Alexander(1947)

SURGICAL INDICATIONS
No sign of neurological recovery after trial of 3-4 weeks
therapy
Neurological complications develop during conservative
treatment
Neuro deficit becoming worse on drugs & bed rest
Recurrence of neurological complication
Prevertebral cervical abscess with difficulty in deglutition &
respiration
Advanced cases- Sphincter involvement, flaccid paralysis
or severe flexor spasms

INDICATIONS.
Recurrent paraplegia
Painful paraplegia d/t root compression, etc
Posterior spinal disease
Spinal tumor syndrome resulting in cord compression
Rapid onset paraplegia (due to thrombosis, etc)
Doubtful diagnosis & for mechanical instability after healing
Cauda equina paralysis

Type of Surgery

SURGICAL APPROACHES

Tulis recommended approach

Cervical spine T1
Anterior approach
Dorsal spine DL junction
Anterolateral approach

Lumbar spine &Lumbosacral junction

Extraperitoneal Transverse Vertebrotomy

ANTERIOR APPROACH TO THE

CERVICAL SPINE (C2 to D1)
Smith & Robinson
Oblique / transverse incision.
Plane b/w SCM & carotid sheath laterally & T-O
medially.
Longitudinal incision in ALL open a perivertebral
abscess, or the diseased vertebrae may be exposed
by reflecting the ALL
& the longus colli muscles.
Hodgson approach via posterior triangle by retracting
SCM,
Carotid sheath, T & O anteriorly & to the opposite
side.

SURGICAL APPROACHES TO
DORSAL SPINE
Anterior transpleural transthoracic approach
(Hodgson &

Stock, 1956)

Anterolateral extrapleural approach (Griffiths,

Seddon & Roaf,
1956)

Posterolateral approach (Martin,1970)

{Dura is exposed by hemilaminectomy first & then
extended laterally to remove the posterior ends
of 2 4
ribs, corresponding transverse processes & the
pedicles}.

TRANSTHORACIC
TRANSPLEURAL
Left sided
incision preferable
Incision made along the rib which in the mid-axillary line,
lies
opposite the centre of the lesion (i.e. usually 2 ribs higher
than the
centre of the vertebral lesion).
For severe kyphosis, a rib along the incision line should be
removed.
J-shaped parascapular incision for C7 D8 lesions, scapula
uplift & rib resection.
After cutting the muscles & periosteum, rib is resected
subperiosteally.

TRANSTHORACIC
TRANSPLEURAL.
Parietal pleural incision applied & lung freed from
the parieties & retracted anteriorly.

A plane developed b/w the descending aorta & the

paravertebral abscess / diseased vertebral bodies by
ligating the intercostal vessels & branches of
hemiazygos veins.
T-shaped incision over the paravertebral abscess.
Debridement / decompression with or without bone

ANTEROLATERAL
DECOMPRESSION
Griffith et al -- prone position
Tuli --- Right lateral position
Advantage:1. avoid venous congestion
2 . avoid excessive bleeding
3. permits free respiration
4. Lung & mediastinal contents fall anteriorly
Parts to remove :
Posterior part of rib (~8cm from the TP)
Transverse process (TP)
Pedicle
Part of the vertebral body

ANTEROLATERAL
DECOMPRESSION.
Semicircular incision
For severe kyphosis, additional 3-4 transverse
processes and
ribs have to be removed.
Intercostal nerves serve as guide to the
intervertebral
foramina & the pedicles.

ANTERO-LATERAL APPROACH TO
LUMBAR SPINE ( LUMBOVERTEBROTOMY)
Left side approach
Semicircular incision
Expose and remove transverse process
subperiosteally.
Preserve lumbar nerves

ANTERO-LATERAL APPROACH TO
LUMBAR SPINE ( LUMBOVERTEBROTOMY)
45 right lateral position with bridge centred over
the area to be exposed.
Similar incision as nephroureterectomy or
sympathectomy
Strip peritoneum off posterior abdominal wall and
kidney, preserving ureter.
Longitudinal incision along psoas fibres for abscess
drainage
Retract the sympathetic chain
Double ligation of lumbar vessels.

EXTRA PERITONEAL APPROACH TO

LUMBO-SACRAL REGION
Left side preferred ( left Common iliac vessels
longer & retracted easily).
Lazy S incision
Strip & reflect the parietal peritoneum along with
ureter & spermatic vessels towards right side.

TRANS PERITONEAL HYPOGASTRIC/

SUPRAPUBIC ANTERIOR APPROACH TO
LUMBO-SACRAL REGION

Supine position
Midline incision from umbilicus to pubis.
Lumbo-sacral region identified distal to aortic
bifurcation and left common iliac vein.
Longitudinal incision on parietal peritoneum over
lumbo-sacral region in midline.
Avoid injury to sacral nerve & artery and
sympathetic ganglion.

POSTERIOR SPINAL
ARTHRODESIS
By Albee & Hibbs
Albee Tibial graft inserted longitudinally in to the
split
spinous processes across the diseased site.
Hibbs overlapping numerous small osseous flaps
from contiguous laminae , spinous processes &
articular facets
Indications
1. Mechanical instability of spine in otherwise
healed disease.
2. To stabilize the craniovertebral region (in
certain cases of T.B.)
3. As a part of panvertebral operation

SURGERY IN SEVERE KYPHOSIS

HIGH RISK PATIENTS:
- Patients < 10 years
- Dorsal lesions
- Involvement of >= 3 vertebrae
- Severe deformity in presence of active disease,
especially in children is an absolute indication for
decompression , correction and stabilization.
Staged operations 1. Anteriorly at the site of disease,
2. Osteotomy of the posterior elements at the
deformity &
3. Halopelvic or halofemoral tractions postoperatively.

TREATMENT OF PARAPLEGIA IN
SEVERE KHYPHOSIS
Griffiths et al (1956) :anterior transposition of cord
through
laminectomy
Rajasekaran (2002): posterior stabilization f/b
anterior
debridement and bone grafting ( titanium
cages) in active
stage of disease and
vice versa for healed disease.
Antero-lateral (Preferred approach) .

SURGICAL CORRECTION OF SEVERE

KYPHOTIC DEFORMITY
Fundamentals of correction:
1. to perform an osteotomy on the
concave side of the curve and wedge it open
( secured with strong autogenous iliac
grafts) .
2. to remove a wedge on the convex side
and close this wedge ( Harrington compression
rods and hooks)

CLINICAL FACTORS INFLUENCING

PROGNOSIS IN CORD INVOLVEMENT

CERVICAL TUBERCULOSIS

Less than 1% of all spinal tuberculosis.

Young patients (14 to 65 years), F: M = 2:1.
Infection from primary sites (paranasal sinuses,
nasopharyngeal or
retropharyngeal lymph nodes) spreads retrograde
via lymphatic route.
PRESENTATION:
2 months to 2 years to produce symptoms
Cervico-medullary compression,
Cranial nerve deficits
Atlanto-axial instability,
Abscess formation

DIAGNOSIS:
X-ray / CT Scan / MRI :
Destruction of lateral masses,
Secondary atlanto-axial subluxation
Basilar invagination,
Adjacent bony destruction,
Increase in the pre-vertebral shadow/
prevertebral enhancing soft tissue
mass.
Spinal cord signal changes / compression.

STAGES OF CVJ
TUBERCULOSIS (Lifeso et al)

TREATMENT

CONSERVATIVE :
Absolute bed rest
Cervical traction for unstable spine
Prolonged external immobilization
ATT X 18 months
SURGERY :
Gross bony destruction with instability
Abscess formation
Severe or progressive neurological deficit
Unstable spine following conservative therapy(failed
therapy)
Doubtful diagnosis (esp. with neoplasm)

REFERENCES
Tuberculosis of Skeletal System SM Tuli - 4th
edn
Spine Surgery Edward C. Benzel 2nd edn
Campbells Operative Orthopaedics 11th edn
Synopsis of Spine Surgery Howard S Ann
The Story of Orthopaedics - Mercer Rang
Harrisons Principles of medicine 17th edn
Chapmans Orthopaedic Surgery 3rd edn

T
H
A
N
K
YOU

Dr Shahid Latheef
+917795664142